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Singh AAV, Yoo SJ, Seed M, Lam CZ, Valverde I. Recent advances in multimodal imaging in tetralogy of fallot and double outlet right ventricle. Curr Opin Cardiol 2024; 39:323-330. [PMID: 38652290 DOI: 10.1097/hco.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
PURPOSE OF REVIEW In the ever-evolving field of medical imaging, this review highlights significant advancements in preoperative and postoperative imaging for Tetralogy of Fallot (TOF) and double outlet right ventricle (DORV) over the past 18 months. RECENT FINDINGS This review showcases innovations in echocardiography such as 3D speckle tracking echocardiography (3DSTE) for assessing right ventricle-pulmonary artery coupling (RVPAC) and Doppler velocity reconstruction (DoVeR) for intracardiac flow fields evaluation. Furthermore, advances in assessment of cardiovascular anatomy using computed tomography (CT) improve the integration of imaging in ablation procedures. Additionally, the inclusion of cardiac magnetic resonance (CMR) parameters as risk score predictors for morbidity, and mortality and for timing of pulmonary valve replacement (PVR) indicates its significance in clinical management. The utilization of 4D flow techniques for postoperative hemodynamic assessment promises new insights into pressure mapping. Lastly, emerging technologies such as 3D printing and 3D virtual reality are expected to improve image quality and surgical confidence in preoperative planning. SUMMARY Developments in multimodality imaging in TOF and DORV are poised to shape the future of clinical practice in this field.
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Affiliation(s)
| | - Shi-Joon Yoo
- Division of Cardiac Imaging, Department of Diagnostic Imaging, The Hospital for Professor of Medical Imaging and Paediatrics at the University of Toronto
| | - Mike Seed
- Division of Cardiology, The Hospital for Sick Children, Professor of Paediatrics at the University of Toronto
| | - Christopher Z Lam
- General Radiology, Department of Diagnostic Imaging, Assistant Professor of Medical Imaging at the University of Toronto
| | - Israel Valverde
- The Hospital for Sick Children, Director of 3D Modeling & Printing Program- Cardiology, Associate Professor of Paediatrics at the University of Toronto, Toronto, Canada
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Mayourian J, Sleeper LA, Lee JH, Lu M, Geva A, Mulder B, Babu‐Narayan SV, Wald RM, Sompolinsky T, Valente AM, Geva T. Development and Validation of a Mortality Risk Score for Repaired Tetralogy of Fallot. J Am Heart Assoc 2024; 13:e034871. [PMID: 38860401 PMCID: PMC11255736 DOI: 10.1161/jaha.123.034871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/29/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Robust risk assessment is crucial for the growing repaired tetralogy of Fallot population at risk of major adverse clinical outcomes; however, current tools are hindered by lack of validation. This study aims to develop and validate a risk prediction model for death in the repaired tetralogy of Fallot population. METHODS AND RESULTS Patients with repaired tetralogy of Fallot enrolled in the INDICATOR (International Multicenter Tetralogy of Fallot Registry) cohort with clinical, arrhythmia, cardiac magnetic resonance, and outcome data were included. Patients from London, Amsterdam, and Boston sites were placed in the development cohort; patients from the Toronto site were used for external validation. Multivariable Cox regression was used to evaluate factors associated with time from cardiac magnetic resonance until the primary outcome: all-cause death. Of 1552 eligible patients (n=1221 in development, n=331 in validation; median age at cardiac magnetic resonance 23.4 [interquartile range, 15.6-35.6] years; median follow up 9.5 years), 102 (6.6%) experienced the primary outcome. The multivariable Cox model performed similarly during development (concordance index, 0.83 [95% CI, 0.78-0.88]) and external validation (concordance index, 0.80 [95% CI, 0.71-0.90]) and identified older age at cardiac magnetic resonance, obesity, type of tetralogy of Fallot repair, higher right ventricular end-systolic volume index, and lower biventricular global function index as independent predictors of death. A risk-scoring algorithm dividing patients into low-risk (score ≤4) versus high-risk (score >4) groups was validated to effectively discriminate risk of death (15-year survival of 95% versus 74%, respectively; P<0.001). CONCLUSIONS This externally validated mortality risk prediction algorithm can help identify vulnerable patients with repaired tetralogy of Fallot who may benefit from targeted interventions.
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Affiliation(s)
- Joshua Mayourian
- Department of Cardiology, Boston Children’s Hospital, Department of PediatricsHarvard Medical SchoolBostonMAUSA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, Department of PediatricsHarvard Medical SchoolBostonMAUSA
| | - Ji Hae Lee
- Department of Cardiology, Boston Children’s Hospital, Department of PediatricsHarvard Medical SchoolBostonMAUSA
| | - Minmin Lu
- Department of Cardiology, Boston Children’s Hospital, Department of PediatricsHarvard Medical SchoolBostonMAUSA
| | - Alon Geva
- Department of Anesthesiology, Critical Care, and Pain Medicine, and Computational Health Informatics Program, Boston Children’s Hospital and Department of AnaesthesiaHarvard Medical SchoolBostonMAUSA
| | - Barbara Mulder
- Department of CardiologyAmsterdam University Medical CentreAmsterdamThe Netherlands
| | - Sonya V. Babu‐Narayan
- Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung Institute, Imperial CollegeLondonUnited Kingdom
| | - Rachel M. Wald
- Division of CardiologyUniversity of Toronto, Peter Munk Cardiac CentreTorontoONCanada
| | - Tehila Sompolinsky
- Department of Cardiology, Boston Children’s Hospital, Department of PediatricsHarvard Medical SchoolBostonMAUSA
| | - Anne Marie Valente
- Department of Cardiology, Boston Children’s Hospital, Department of PediatricsHarvard Medical SchoolBostonMAUSA
| | - Tal Geva
- Department of Cardiology, Boston Children’s Hospital, Department of PediatricsHarvard Medical SchoolBostonMAUSA
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Roy LO, Blais S, Marelli A, Dahdah N, Dancea A, Drolet C, Dallaire F. Outcomes After Pediatric Pulmonary Valve Replacement in Patients With Tetralogy of Fallot. Can J Cardiol 2024:S0828-282X(24)00441-0. [PMID: 38889848 DOI: 10.1016/j.cjca.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/05/2024] [Accepted: 06/07/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND People with tetralogy of Fallot might require a transannular patch during primary repair, which leads to pulmonary valve regurgitation. Pulmonary valve replacement (PVR) is performed to prevent complications of chronic pulmonary regurgitation, but the optimal timing of PVR remains a matter of debate. In this study we aimed to assess the association of PVR performed in children younger than 18 years of age with the rate of hospitalizations, interventions, and mortality. METHODS This was a retrospective observational cohort of people with tetralogy of Fallot born in Québec between 1982 and 2015, using a combination of clinical and administrative data. Marginal means and rates models and survival curves were used to compare outcomes of patients with pediatric PVR (younger than 18 years) and those without. Outcomes of interest were rates of cardiac hospitalizations, all-cause hospitalizations, cardiac interventions, and mortality. Groups were balanced using models weighed on the inverse probability of receiving pediatric PVR. RESULTS Of the 316 eligible patients, 58 (18.4%) received a pediatric PVR. Compared with patients who did not receive pediatric PVR, they were at increased risk of cardiac hospitalizations, although the rates of cardiac hospitalization were low: 0.50 vs 0.09 hospitalizations per 20 years (hazard ratio [HR] = 4.71 [95% confidence interval (CI), 2.22-9.96]). Patients who received a pediatric PVR had a comparable risk of all-cause hospitalizations (HR = 0.95 [95% CI, 0.71-1.26]) and of cardiac interventions (HR = 1.13 [95% CI, 0.72-1.77]). CONCLUSIONS Patients who underwent pediatric PVR had higher rates of cardiac hospitalizations, but similar rates of all-cause hospitalizations, cardiac procedures, and mortality. In this observational cohort, pediatric PVR was not associated with an improved outcome.
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Affiliation(s)
- Louis-Olivier Roy
- Department of Pediatrics, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Samuel Blais
- Department of Pediatrics, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence, McGill University Health Centre, Montréal, Québec, Canada
| | - Nagib Dahdah
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Adrian Dancea
- Division of Cardiology, Montreal Children's Hospital, McGill University Health Center, Montréal, Québec, Canada
| | - Christian Drolet
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire de Québec, Québec City, Québec, Canada
| | - Frédéric Dallaire
- Department of Pediatrics, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada.
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Flores-Umanzor E, Alshehri B, Keshvara R, Wilson W, Osten M, Benson L, Abrahamyan L, Horlick E. Transcatheter-Based Interventions for Tetralogy of Fallot Across All Age Groups. JACC Cardiovasc Interv 2024; 17:1079-1090. [PMID: 38749587 DOI: 10.1016/j.jcin.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/31/2024] [Accepted: 02/13/2024] [Indexed: 05/26/2024]
Abstract
Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease. Palliative procedures, either surgical or transcatheter, aim to improve oxygen saturation, affording definitive procedures at a later stage. Transcatheter interventions have been used before and after surgical palliative or definitive repair in children and adults. This review aims to provide an overview of the different catheter-based interventions for TOF across all age groups, with an emphasis on palliative interventions, such as patent arterial duct stenting, right ventricular outflow tract stenting, or balloon pulmonary valvuloplasty in infants and children and transcatheter pulmonary valve replacement in adults with repaired TOF, including the available options for a large, dilated native right ventricular outflow tract.
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Affiliation(s)
- Eduardo Flores-Umanzor
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Bandar Alshehri
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Rajesh Keshvara
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - William Wilson
- Royal Melbourne Hospital Cardiology, Parkville, Victoria, Australia
| | - Mark Osten
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Lee Benson
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; The Labatt Family Heart Centre, Division of Cardiology, The Hospital for Sick Children, The Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
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Leonardi B, Perrone M, Calcaterra G, Sabatino J, Leo I, Aversani M, Bassareo PP, Pozza A, Oreto L, Moscatelli S, Borrelli N, Bianco F, Di Salvo G. Repaired Tetralogy of Fallot: Have We Understood the Right Timing of PVR? J Clin Med 2024; 13:2682. [PMID: 38731211 PMCID: PMC11084704 DOI: 10.3390/jcm13092682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/23/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Despite many advances in surgical repair during the past few decades, the majority of tetralogy of Fallot patients continue to experience residual hemodynamic and electrophysiological abnormalities. The actual issue, which has yet to be solved, is understanding how this disease evolves in each individual patient and, as a result, who is truly at risk of sudden death, as well as the proper timing of pulmonary valve replacement (PVR). Our responsibility should be to select the most appropriate time for each patient, going above and beyond imaging criteria used up to now to make such a clinically crucial decision. Despite several studies on timing, indications, procedures, and outcomes of PVR, there is still much uncertainty about whether PVR reduces arrhythmia burden or improves survival in these patients and how to appropriately manage this population. This review summarizes the most recent research on the evolution of repaired tetralogy of Fallot (from adolescence onwards) and risk factor variables that may favor or delay PVR.
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Affiliation(s)
| | - Marco Perrone
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
- Division of Cardiology and CardioLab, Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | | | - Jolanda Sabatino
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Isabella Leo
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Martina Aversani
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Pier Paolo Bassareo
- School of Medicine, University College of Dublin, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland;
| | - Alice Pozza
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Lilia Oreto
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, 98122 Messina, Italy;
| | - Sara Moscatelli
- Institute of Cardiovascular Sciences University College London, London WC1E 6BT, UK and Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London WC1N 3JH, UK;
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, AO Dei Colli, Monaldi Hospital, 80131 Naples, Italy;
| | - Francesco Bianco
- Cardiovascular Sciences Department, AOU “Ospedali Riuniti”, 60126 Ancona, Italy;
| | - Giovanni Di Salvo
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
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Watelle L, Roy LO, Lauzon-Schnitka J, Newell G, Dumas A, Nadeau A, Xiong WT, Rego K, Beaulieu C, Groulx-Boivin E, Roy-Lacroix MÈ, Vaujois L, Drolet C, Dancea A, Dahdah N, Bigras JL, Dallaire F. The Quebec Congenital Heart Disease Registry: A Model of Prospective Databank to Facilitate Research in Congenital Cardiology. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2024; 3:57-66. [PMID: 38774679 PMCID: PMC11103037 DOI: 10.1016/j.cjcpc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/12/2023] [Indexed: 05/24/2024]
Abstract
Background A national registry of congenital heart disease (CHD) would facilitate project initiation, decrease costs, increase statistical power, and avoid duplication. Establishing such registries poses numerous challenges, but the current Canadian research ecosystem in CHD is well positioned to meet them. We assessed the feasibility of building a province-wide CHD registry by automatically identifying people with CHD and extracting their native cardiac anatomy from multiple clinical data sources, without the need for manual data entry. Methods We designed a CHD registry of all fetuses and children with at least 1 echocardiographic report confirming CHD since 2000. We interfaced the registry with several clinical and echocardiography data sources from all paediatric cardiology programmes in Québec. Results We extracted 885,287 echocardiogram reports and 70,121 clinical records. We identified CHD in 43,452 children and 4682 fetuses. There were 1128 (2.3%) cases with files in multiple institutions, and patients with more complex CHD were 3 times more likely to be seen in more than 1 institution. So far, the registry has been used to build and link CHD cohorts for 7 distinct projects. Conclusions We demonstrated the feasibility of a baseline CHD registry in Québec without the need for manual data entry, in which other CHD research projects could be nested. This could serve as a blueprint to expand the registry and to develop an integrated approach where data gathered in caring for patients with CHD serve as data layers that incrementally contribute to a national cohort, for which data remain easily accessible and usable.
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Affiliation(s)
- Laurence Watelle
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Louis-Olivier Roy
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Jonathan Lauzon-Schnitka
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Garrett Newell
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Anne Dumas
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Alexandre Nadeau
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Wei Ting Xiong
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Kevin Rego
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Camille Beaulieu
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Emilie Groulx-Boivin
- Division of Cardiology, Montreal Children’s Hospital, McGill University, Montreal, Québec, Canada
| | - Marie-Ève Roy-Lacroix
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Laurence Vaujois
- Department of Pediatrics, CHU de Québec, Université Laval, Québec, Québec, Canada
| | - Christian Drolet
- Department of Pediatrics, CHU de Québec, Université Laval, Québec, Québec, Canada
| | - Adrian Dancea
- Division of Cardiology, Montreal Children’s Hospital, McGill University, Montreal, Québec, Canada
| | - Nagib Dahdah
- Division of Pediatric Cardiology, CHU Ste-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Jean-Luc Bigras
- Division of Pediatric Cardiology, CHU Ste-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Frédéric Dallaire
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Canadian Congenital and Pediatric Cardiology Research Network (CCPCRN) investigators
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
- Division of Cardiology, Montreal Children’s Hospital, McGill University, Montreal, Québec, Canada
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, and Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
- Department of Pediatrics, CHU de Québec, Université Laval, Québec, Québec, Canada
- Division of Pediatric Cardiology, CHU Ste-Justine, Université de Montréal, Montréal, Québec, Canada
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Dib N, Chauvette V, Diop MS, Bouhout I, Hadid M, Vô C, Khairy P, Poirier N. Tetralogy of Fallot in Low- and Middle-Income Countries. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2024; 3:67-73. [PMID: 38774683 PMCID: PMC11103033 DOI: 10.1016/j.cjcpc.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/09/2023] [Indexed: 05/24/2024]
Abstract
Low- and middle-incomes countries (LMICs) have limited resources for the diagnosis and treatment of congenital heart diseases such as tetralogy of Fallot. This is in part due to lack of infrastructures, financial means, and expertise. As a result, patients undergo surgery much later than in high-income countries. This delay in treatment results in right ventricular dysfunction, cardiac arrhythmias, and poor psychomotor development-complications that are all related to chronic hypoxia. There are limited data and a few small studies of patients treated for tetralogy of Fallot in LMICs, and, therefore, the aim of this review is to analyse and summarize the surgical outcomes of this LMIC population.
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Affiliation(s)
- Nabil Dib
- Division of Pediatric Cardiac Surgery, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Vincent Chauvette
- Division of Pediatric Cardiac Surgery, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Momar Sokhna Diop
- Thoracic and Cardiovascular Surgery Department, CHU Fann, Dakar, Senegal
| | - Ismail Bouhout
- Division of Pediatric Cardiac Surgery, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Mehdi Hadid
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Christophe Vô
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Paul Khairy
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Québec, Canada
- Electrophysiology Service, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Nancy Poirier
- Division of Pediatric Cardiac Surgery, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Québec, Canada
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Roy LO, Blais S, Marelli A, Dahdah N, Dancea A, Drolet C, Dallaire F. Determinants and Clinical Outcomes of Patients With Tetralogy of Fallot Lost to Cardiology Follow-up. Can J Cardiol 2024; 40:411-418. [PMID: 37863391 DOI: 10.1016/j.cjca.2023.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/21/2023] [Accepted: 10/09/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Various rates of loss to follow-up (LTFU) have been reported in patients with congenital heart disease, but return to follow-up is rarely considered in those analyses. Outcomes of LTFU patients are difficult to assess because the patients no longer attend cardiac care. We leveraged data from the TRIVIA cohort, which combines more than 30 years of clinical and administrative data, allowing us to study outcomes even after LTFU. METHODS This population-based cohort included 904 patients with tetralogy of Fallot (TOF) born from 1982 to 2015 in Québec, Canada. Risk factors for LTFU and outcomes were calculated by Cox models and marginal means/rates models. Outcomes of LTFU patients were compared with propensity score-matched non-LTFU patients. RESULTS The cumulative risk of experiencing 1 episode of LTFU was 50.3% at 30 years. However, return to follow-up was frequent and the proportion of patients actively followed was 85.9% at 10 years, 76.4% at 20 years, and 70.6% at 30 years. Factors associated with a reduced risk of LTFU were primary repair with conduit (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.15-0.58) and transannular patch (HR 0.60, 95% CI 0.46-0.79). LTFU patients had lower rates of cardiac hospitalisations (HR 0.49, 95% CI 0.42-0.56) and cardiac interventions (HR 0.32, 95% CI 0.25-0.42), but similar rates of cardiac mortality (HR 0.95, 95% CI 0.24-3.80). CONCLUSIONS There was a lower proportion of LTFU patients compared with previous studies. Factors associated with lower rates of LTFU were conduits and non-valve-sparing surgery. LTFU patients had lower rates of cardiac procedures and cardiac hospitalisations.
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Affiliation(s)
- Louis-Olivier Roy
- Department of Pediatrics, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Samuel Blais
- Department of Pediatrics, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence, McGill University Health Centre, Montréal, Québec, Canada
| | - Nagib Dahdah
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Adrian Dancea
- Division of Cardiology, Montréal Children's Hospital, McGill University Health Center, Montréal, Québec, Canada
| | - Christian Drolet
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire de Québec, Québec City, Québec, Canada
| | - Frédéric Dallaire
- Department of Pediatrics, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada.
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9
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Truesdell W, Salavitabar A, Zampi JD, Agarwal P, Joshi A. An Imager's Overview to Transcatheter Pulmonic Valve Replacement. Semin Roentgenol 2024; 59:76-86. [PMID: 38388100 DOI: 10.1053/j.ro.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/22/2023] [Accepted: 11/22/2023] [Indexed: 02/24/2024]
Affiliation(s)
| | - Arash Salavitabar
- Department of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH
| | - Jeffrey D Zampi
- Department of Pediatric Cardiology, Michigan Medicine, Ann Arbor, MI
| | - Prachi Agarwal
- Department of Radiology, Michigan Medicine, Ann Arbor, MI
| | - Aparna Joshi
- Department of Radiology, Michigan Medicine, Ann Arbor, MI
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10
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Kakarla J, Denham NC, Ishikita A, Oechslin E, Alonso-Gonzalez R, Nair K. Risk Stratification for Sudden Cardiac Death in Repaired Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:414-425. [PMID: 38161672 PMCID: PMC10755789 DOI: 10.1016/j.cjcpc.2023.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/18/2023] [Indexed: 01/03/2024]
Abstract
There has been significant progress in the prevention of sudden cardiac death in repaired tetralogy of Fallot. Contemporary cohorts report greater survival attributable to improved surgical techniques, heart failure management, and proactive strategies for risk stratification and management of ventricular arrhythmias including defibrillator implantation and ablation technology. Over the last 25 years, our understanding of predictive risk factors has also improved from invasive and more limited measures to individualized risk prediction scores based on extensive demographic, imaging, electrophysiological, and functional data. Although each of these contemporary scoring systems improves prediction, there are important differences between the study cohorts, included risk factors, and imaging modalities that can significantly affect interpretation and implementation for the individual patient. In addition, accurate phenotyping of disease complexity and anatomic repair substantially modulates this risk and the mechanism of sudden death. Routine implementation of risk stratification within repaired tetralogy of Fallot management is important and directly informs primary prevention defibrillator implantation as well as consideration for proactive invasive strategies including ventricular tachycardia ablation and pulmonary valve replacement. Assessment and risk stratification by a multidisciplinary team of experts in adult congenital heart disease are crucial and critical. Although we have increased understanding, reconciliation of these complex factors for the individual patient remains challenging and often requires careful consideration and discussion with multidisciplinary teams, patients, and their families.
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Affiliation(s)
- Jayant Kakarla
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Nathan C. Denham
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Ayako Ishikita
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Erwin Oechslin
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Krishnakumar Nair
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
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Dallaire F, Grewal J, Mawad W, Wald RM. Challenges and Opportunities for Patients With Tetralogy of Fallot Across the Lifespan. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:253-255. [PMID: 38161677 PMCID: PMC10755820 DOI: 10.1016/j.cjcpc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/05/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Frédéric Dallaire
- Department of Pediatrics, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Jasmine Grewal
- Division of Cardiology, St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wadi Mawad
- Division of Cardiology, Montreal Children’s Hospital, McGill University Health Center, Montreal, Québec, Canada
| | - Rachel M. Wald
- University Health Network, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, University of Toronto, Toronto, Ontario, Canada
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12
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Garagiola ML, Thorne SA. Pregnancy Considerations in Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:301-313. [PMID: 38161671 PMCID: PMC10755828 DOI: 10.1016/j.cjcpc.2023.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/12/2023] [Indexed: 01/03/2024]
Abstract
The majority of women with repaired tetralogy of Fallot are able to tolerate pregnancy with a low risk of cardiovascular events. However, proactive contraceptive advice, prepregnancy counselling, and care by a pregnancy heart team with expertise in congenital heart disease are key to ensuring a good outcome for mother and baby. Maternal and fetal risks are increased in the presence of severe valvular stenosis, poorly tolerated arrhythmia, significant ventricular dysfunction, and cyanosis. It is unusual to see cyanotic adults with tetralogy of Fallot, whether unoperated or shunt palliated; pregnancy risks are greatly reduced by completing their repair before pregnancy is undertaken. The multidisciplinary pregnancy heart team should make a risk-stratified pregnancy care plan using a combination of published scoring systems and an individualized assessment of the patient's comorbidities. Low-risk patients may have the majority of their care and give birth in local units, whereas those at high risk should be managed and give birth in a tertiary centre with high-level expertise and intensive care facilities. Age-appropriate conversations about future childbearing and safe and reliable contraception should be part of routine follow-up from teenage years, so that women with tetralogy of Fallot can control their own fertility and make informed decisions about having children.
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Affiliation(s)
- Maria L. Garagiola
- Division of Cardiology, University Health Network and Mount Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Sara A. Thorne
- Division of Cardiology, University Health Network and Mount Sinai Health System, University of Toronto, Toronto, Ontario, Canada
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13
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Bassett AS, Reuter MS, Malecki S, Silversides C, Oechslin E. Clinically Relevant Genetic Considerations for Patients With Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:426-439. [PMID: 38161665 PMCID: PMC10755827 DOI: 10.1016/j.cjcpc.2023.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/05/2023] [Indexed: 01/03/2024]
Abstract
Genetic changes affect embryogenesis, cardiac and extracardiac phenotype, development, later onset conditions, and both short- and long-term outcomes and comorbidities in the increasing population of individuals with tetralogy of Fallot (TOF). In this review, we focus on current knowledge about clinically relevant genetics for patients with TOF across the lifespan. The latest findings for TOF genetics that are pertinent to day-to-day practice and lifelong management are highlighted: morbidity/mortality, cardiac/extracardiac features, including neurodevelopmental expression, and recent changes to prenatal screening and diagnostics. Genome-wide microarray is the first-line clinical genetic test for TOF across the lifespan, detecting relevant structural changes including the most common for TOF, the 22q11.2 microdeletion. Accumulating evidence illustrates opportunities for advances in understanding and care that may arise from genetic diagnosis at any age. We also glimpse into the near future when the multigenic nature of TOF will be more fully revealed, further enhancing possibilities for preventive care. Precision medicine is nigh.
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Affiliation(s)
- Anne S. Bassett
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, and Campbell Family Mental Health Research Institute, Toronto, Ontario, Canada
| | - Miriam S. Reuter
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Sarah Malecki
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Candice Silversides
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Erwin Oechslin
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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14
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Vô C, Dib N, Bartoletti S, Gonzalez CM, Mondésert B, Gagnon MH, Fournier A, Khairy P. Navigating Arrhythmias in Tetralogy of Fallot Throughout the Lifespan: A Case-based Review. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:404-413. [PMID: 38161682 PMCID: PMC10755829 DOI: 10.1016/j.cjcpc.2023.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/12/2023] [Indexed: 01/03/2024]
Abstract
Arrhythmias are a common complication associated with tetralogy of Fallot (ToF), one of the most prevalent forms of congenital heart disease. As illustrated by this case-based review, various forms of arrhythmias can be encountered across the lifespan of patients with ToF, from infancy to older adulthood. These include atrioventricular block, junctional ectopic tachycardia, and atrial and ventricular arrhythmias. Arrhythmias have important implications on the health and quality of life of patients with ToF and require treatment by caregivers with dedicated expertise. The choice of pharmacologic and/or interventional therapies to alleviate symptoms, avoid complications, and mitigate risks depends in part on the type, severity, and frequency of the arrhythmia, as well as on the particularities of individual clinical scenarios. Preventing, monitoring for, and managing arrhythmias are an integral component of the care of patients with ToF throughout their lifespan that is critical to optimizing health outcomes.
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Affiliation(s)
- Christophe Vô
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
- Electrophysiology Service, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Nabil Dib
- Division of Pediatric Cardiac Surgery, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Stefano Bartoletti
- Electrophysiology Service, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Cecilia M. Gonzalez
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Blandine Mondésert
- Electrophysiology Service, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Marie-Hélène Gagnon
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Anne Fournier
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Paul Khairy
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
- Electrophysiology Service, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
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15
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Mackie AS, Bravo-Jaimes K, Keir M, Sillman C, Kovacs AH. Access to Specialized Care Across the Lifespan in Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:267-282. [PMID: 38161668 PMCID: PMC10755796 DOI: 10.1016/j.cjcpc.2023.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/05/2023] [Indexed: 01/03/2024]
Abstract
Individuals living with tetralogy of Fallot require lifelong specialized congenital heart disease care to monitor for and manage potential late complications. However, access to cardiology care remains a challenge for many patients, as does access to mental health services, dental care, obstetrical care, and other specialties required by this population. Inequities in health care access were highlighted by the COVID-19 pandemic and continue to exist. Paradoxically, many social factors influence an individual's need for care, yet inadvertently restrict access to it. These include sex and gender, being a member of a racial or ethnic historically excluded group, lower educational attainment, lower socioeconomic status, living remotely from tertiary care centres, transportation difficulties, inadequate health insurance, occupational instability, and prior experiences with discrimination in the health care setting. These factors may coexist and have compounding effects. In addition, many patients believe that they are cured and unaware of the need for specialized follow-up. For these reasons, lapses in care are common, particularly around the time of transfer from paediatric to adult care. The lack of trained health care professionals for adults with congenital heart disease presents an additional barrier, even in higher income countries. This review summarizes challenges regarding access to multiple domains of specialized care for individuals with tetralogy of Fallot, with a focus on the impact of social determinants of health. Specific recommendations to improve access to care within Canadian and American systems are offered.
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Affiliation(s)
- Andrew S. Mackie
- Division of Cardiology, Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Katia Bravo-Jaimes
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michelle Keir
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christina Sillman
- Adult Congenital Heart Disease Program, Sutter Heart and Vascular Institute, Sacramento, California, USA
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16
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Hammett O, Griksaitis MJ. Management of tetralogy of Fallot in the pediatric intensive care unit. Front Pediatr 2023; 11:1104533. [PMID: 37360374 PMCID: PMC10285149 DOI: 10.3389/fped.2023.1104533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/26/2023] [Indexed: 06/28/2023] Open
Abstract
Tetralogy of Fallot (ToF) is one of the most common congenital cyanotic heart lesions and can present to a variety of health care professionals, including teams working in pediatric intensive care. Pediatric intensive care teams may care for a child with ToF pre-operatively, peri-operatively, and post-operatively. Each stage of management presents its own unique challenges. In this paper we discuss the role of pediatric intensive care in each stage of management.
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Affiliation(s)
- Owen Hammett
- Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Dorset and Somerset Air Ambulance, South Western Ambulance Service NHS Foundation Trust, Exeter, United Kingdom
| | - Michael J. Griksaitis
- Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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17
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Miller JR, Stephens EH, Goldstone AB, Glatz AC, Kane L, Van Arsdell GS, Stellin G, Barron DJ, d'Udekem Y, Benson L, Quintessenza J, Ohye RG, Talwar S, Fremes SE, Emani SM, Eghtesady P. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot. J Thorac Cardiovasc Surg 2023; 165:221-250. [PMID: 36522807 DOI: 10.1016/j.jtcvs.2022.07.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice. METHODS The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement. RESULTS In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation. CONCLUSIONS Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.
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Affiliation(s)
- Jacob R Miller
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
| | | | - Andrew B Goldstone
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiothoracic Surgery, Columbia University, New York, NY
| | - Andrew C Glatz
- Division of Pediatrics, Department of Pediatric Cardiology, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
| | | | - Glen S Van Arsdell
- Division of Cardiothoracic Surgery, Department of Surgery, UCLA Mattel Children's Hospital, Los Angeles, Calif
| | - Giovanni Stellin
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Lee Benson
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Quintessenza
- Department of Cardiovascular Surgery, Johns Hopkins All Children's Heart Institute, St Petersburg, Fla
| | - Richard G Ohye
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | - Sachin Talwar
- Department of Cariothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sitaram M Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass.
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
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18
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Wu MH, Wang JK, Chiu SN, Lu CW, Lin MT, Chen CA, Tseng WC. Long-term outcome of repaired tetralogy of Fallot: Survival, tachyarrhythmia, and impact of pulmonary valve replacement. Heart Rhythm 2022; 19:1856-1863. [PMID: 35781043 DOI: 10.1016/j.hrthm.2022.06.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pulmonary valve replacement (PVR) is recommended for severe pulmonary regurgitation in repaired tetralogy of Fallot (rTOF). OBJECTIVE The purpose of this study was to investigate the event rate and effectiveness of PVR. METHODS A retrospective study of tetralogy of Fallot patients who survived total repair from 1970 to 2020 was conducted. RESULTS We identified 1744 rTOF patients; 86.6% with classic rTOF, 11.5% with pulmonary atresia, 0.8% with endocardial cushion defect, and 1.1% with absent pulmonary valve. Annual risks of tachyarrhythmia/sudden cardiac arrest (SCA) increased to 0.295% and 1.338% in patients aged 10-30 and 30-60 years, respectively, without sex predominance. PVR (223 surgical and 39 percutaneous) event rate was 34.7% ± 2.1% by 30 years after repair (annual risk: 1.57% between 10 and 30 years after repair). The second PVR rate was 9.9% ± 4.1% by 20 years after the first PVR. Tachyarrhythmia/SCA risk was higher in PVR patients than in No PVR patients and was reduced in PVR patients without tachyarrhythmia/SCA before PVR. However, survival in patients with ventricular tachyarrhythmia/SCA still was better after PVR. At PVR, 13% of patients had tachyarrhythmia/SCA, which was the major predictor of events after PVR. Before PVR, although the ventricular tachyarrhythmia/SCA risks included QRS duration >160 ms and New York Heart Association functional class III or IV, supraventricular tachyarrhythmia was associated with PVR age ≥28 years and N-terminal pro-brain natriuretic peptide >450 pg/mL. CONCLUSION Tachyarrhythmia/SCA occurrence and the need for PVR increased with age during young adulthood. PVR reduced subsequent arrhythmias only in those patients without arrhythmias before PVR.
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Affiliation(s)
- Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan.
| | - Jou-Kou Wang
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Sheunn-Nan Chiu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Chun-Wei Lu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Ming-Tai Lin
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Chun-An Chen
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Wei-Chieh Tseng
- Department of Emergency Medicine, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
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19
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Calcagni G, Calvieri C, Baban A, Bianco F, Barracano R, Caputo M, Madrigali A, Silva Kikina S, Perrone MA, Digilio MC, Pozzi M, Secinaro A, Sarubbi B, Galletti L, Gagliardi MG, de Zorzi A, Drago F, Leonardi B. Syndromic and Non-Syndromic Patients with Repaired Tetralogy of Fallot: Does It Affect the Long-Term Outcome? J Clin Med 2022; 11:jcm11030850. [PMID: 35160301 PMCID: PMC8836447 DOI: 10.3390/jcm11030850] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 12/10/2022] Open
Abstract
Background: The impact of genetic syndromes on cardiac magnetic resonance imaging (cMRI) parameters, particularly on right and/or left ventricular dysfunction, associated with clinical parameters following the repair of Tetralogy of Fallot (rToF) is not well known. Therefore, this study aimed to assess the differences in clinical, surgical, and cMRI data in syndromic and non-syndromic rToF patients. Methods: All syndromic rToF patients undergoing a cMRI without general anesthesia between 2010 and 2020 who were able to match with non-syndromic ones for birth date, sex, type of surgery, timing of cMRI, and BSA were selected. Demographic, clinical, surgical, MRI, ECG, and Holter ECG data were collected. Results: A total of one hundred and eight rToF patients equally subdivided into syndromic and non-syndromic, aged 18.7 ± 7.3 years, were studied. Del22q11.2 and Down syndrome (DS) were the most frequent syndromes (42.6% and 31.5%, respectively). Regarding the cMRI parameters considered, left ventricular (LV) dysfunction (LVEF < 50%) was more frequently found in syndromic patients (p = 0.040). In addition, they were older at repair (p = 0.002) but underwent earlier pulmonary valve replacement (PVR) (15.9 ± 5.6 vs. 19.5 ± 6.0 years, p = 0.049). On multivariate Cox regression analysis, adjusted for age at first repair, LV dysfunction remained significantly more associated with DS than del22q11.2 and non-syndromic patients (HR of 5.245; 95% CI 1.709–16.100, p = 0.004). There were only four episodes of non-sustained ventricular tachycardia in our cohort. Conclusions: Among the cMRI parameters commonly taken into consideration in rToF patients, LV dysfunction seemed to be the only one affected by the presence of a genetic syndrome. The percentage of patients performing PVR appears to be similar in both populations, although syndromic patients were older at repair and younger at PVR. Finally, the number of arrhythmic events in rToF patients seems to be low and unaffected by chromosomal abnormalities.
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Affiliation(s)
- Giulio Calcagni
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (G.C.); (C.C.); (A.B.); (A.M.); (S.S.K.); (M.A.P.); (L.G.); (M.G.G.); (A.d.Z.); (F.D.)
| | - Camilla Calvieri
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (G.C.); (C.C.); (A.B.); (A.M.); (S.S.K.); (M.A.P.); (L.G.); (M.G.G.); (A.d.Z.); (F.D.)
| | - Anwar Baban
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (G.C.); (C.C.); (A.B.); (A.M.); (S.S.K.); (M.A.P.); (L.G.); (M.G.G.); (A.d.Z.); (F.D.)
| | - Francesco Bianco
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, AOU Ospedali Riuniti Ancona “Umberto I, G. M. Lancisi, G. Salesi”, 60123 Ancona, Italy; (F.B.); (M.P.)
| | - Rosaria Barracano
- Adult Congenital Heart Disease Unit, Monaldi Hospital, 80131 Naples, Italy; (R.B.); (B.S.)
| | - Massimo Caputo
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol BS2 8 HW, UK;
| | - Andrea Madrigali
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (G.C.); (C.C.); (A.B.); (A.M.); (S.S.K.); (M.A.P.); (L.G.); (M.G.G.); (A.d.Z.); (F.D.)
| | - Stefani Silva Kikina
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (G.C.); (C.C.); (A.B.); (A.M.); (S.S.K.); (M.A.P.); (L.G.); (M.G.G.); (A.d.Z.); (F.D.)
| | - Marco Alfonso Perrone
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (G.C.); (C.C.); (A.B.); (A.M.); (S.S.K.); (M.A.P.); (L.G.); (M.G.G.); (A.d.Z.); (F.D.)
| | - Maria Cristina Digilio
- Genetics and Rare Diseases Research Division, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy;
| | - Marco Pozzi
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, AOU Ospedali Riuniti Ancona “Umberto I, G. M. Lancisi, G. Salesi”, 60123 Ancona, Italy; (F.B.); (M.P.)
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Department of Imaging, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy;
| | - Berardo Sarubbi
- Adult Congenital Heart Disease Unit, Monaldi Hospital, 80131 Naples, Italy; (R.B.); (B.S.)
| | - Lorenzo Galletti
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (G.C.); (C.C.); (A.B.); (A.M.); (S.S.K.); (M.A.P.); (L.G.); (M.G.G.); (A.d.Z.); (F.D.)
| | - Maria Giulia Gagliardi
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (G.C.); (C.C.); (A.B.); (A.M.); (S.S.K.); (M.A.P.); (L.G.); (M.G.G.); (A.d.Z.); (F.D.)
| | - Andrea de Zorzi
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (G.C.); (C.C.); (A.B.); (A.M.); (S.S.K.); (M.A.P.); (L.G.); (M.G.G.); (A.d.Z.); (F.D.)
| | - Fabrizio Drago
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (G.C.); (C.C.); (A.B.); (A.M.); (S.S.K.); (M.A.P.); (L.G.); (M.G.G.); (A.d.Z.); (F.D.)
| | - Benedetta Leonardi
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy; (G.C.); (C.C.); (A.B.); (A.M.); (S.S.K.); (M.A.P.); (L.G.); (M.G.G.); (A.d.Z.); (F.D.)
- Correspondence: ; Tel.: +39-06-68594979
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McElhinney DB, Zhang Y, Levi DS, Georgiev S, Biernacka EK, Goldstein BH, Shahanavaz S, Qureshi AM, Cabalka AK, Bauser-Heaton H, Torres AJ, Morray BH, Armstrong AK, Millan-Iturbe O, Peng LF, Aboulhosn JA, Rużyłło W, Berger F, Sondergaard L, Schranz D, Cheatham JP, Jones TK, Ewert P, Schubert S. Reintervention and Survival After Transcatheter Pulmonary Valve Replacement. J Am Coll Cardiol 2022; 79:18-32. [PMID: 34991785 DOI: 10.1016/j.jacc.2021.10.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Transcatheter pulmonary valve (TPV) replacement (TPVR) has become the standard therapy for postoperative pulmonary outflow tract dysfunction in patients with a prosthetic conduit/valve, but there is limited information about risk factors for death or reintervention after this procedure. OBJECTIVES This study sought to evaluate mid- and long-term outcomes after TPVR in a large multicenter cohort. METHODS International registry focused on time-related outcomes after TPVR. RESULTS Investigators submitted data for 2,476 patients who underwent TPVR and were followed up for 8,475 patient-years. A total of 95 patients died after TPVR, most commonly from heart failure (n = 24). The cumulative incidence of death was 8.9% (95% CI: 6.9%-11.5%) 8 years after TPVR. On multivariable analysis, age at TPVR (HR: 1.04 per year; 95% CI: 1.03-1.06 per year; P < 0.001), a prosthetic valve in other positions (HR: 2.1; 95% CI: 1.2-3.7; P = 0.014), and an existing transvenous pacemaker/implantable cardioverter-defibrillator (HR: 2.1; 95% CI: 1.3-3.4; P = 0.004) were associated with death. A total of 258 patients underwent TPV reintervention. At 8 years, the cumulative incidence of any TPV reintervention was 25.1% (95% CI: 21.8%-28.5%) and of surgical TPV reintervention was 14.4% (95% CI: 11.9%-17.2%). Risk factors for surgical reintervention included age (0.95 per year [95% CI: 0.93-0.97 per year]; P < 0.001), prior endocarditis (2.5 [95% CI: 1.4-4.3]; P = 0.001), TPVR into a stented bioprosthetic valve (1.7 [95% CI: 1.2-2.5]; P = 0.007), and postimplant gradient (1.4 per 10 mm Hg [95% CI: 1.2-1.7 per 10 mm Hg]: P < 0.001). CONCLUSIONS These findings support the conclusion that survival and freedom from reintervention or surgery after TPVR are generally comparable to outcomes of surgical conduit/valve replacement across a wide age range.
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Affiliation(s)
| | - Yulin Zhang
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Daniel S Levi
- Mattel Children's Hospital at UCLA, Los Angeles, California, USA
| | | | | | - Bryan H Goldstein
- Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Shabana Shahanavaz
- Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | | | | | - Holly Bauser-Heaton
- Sibley Heart Center at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Alejandro J Torres
- New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA
| | - Brian H Morray
- Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | | | | | - Lynn F Peng
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Jamil A Aboulhosn
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Witold Rużyłło
- The Cardinal Stefan Wyszyński Institute of Cardiology, Warsaw, Poland
| | | | - Lars Sondergaard
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Thomas K Jones
- Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
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21
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Chang YL, Kuan TH, Chen CH, Tsai YJ, Chen GB, Lin KL, Tuan SH. Differences in Cardiopulmonary Fitness Between Boy and Girls With Repaired Tetralogy of Fallot. Front Pediatr 2022; 10:911825. [PMID: 35874578 PMCID: PMC9298839 DOI: 10.3389/fped.2022.911825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Many studies have demonstrated that patients with repaired tetralogy of Fallot (rTOF) have generally poorer cardiopulmonary fitness (CPF). However, little is known about how the disease results in different CPF in each sex. Therefore, this study aimed to investigate whether sex (and gender) differences affect CPF in children and adolescents with rTOF. METHODS This retrospective study recruited adolescents and children (aged 10-18) with rTOF following an acute stage of tetralogy of Fallot (TOF) who received cardiopulmonary exercise testing (CPET) in the past 10 years. CPF was determined by symptom-limited CPET with a treadmill under ramped Bruce protocol. Boys and girls were categorized into groups based on body mass index (BMI) and fat mass index (FMI). The BMI was grouped by Taiwanese obesity cutoff points. The FMI was categorized by the body fat percentage. Excess adiposity was defined as (1) "overweight" and "obese" by BMI and (2) greater than the sex- and age-specific 75th percentile of whole subjects by FMI. RESULTS A total of 185 participants (104 boys and 81 girls) with rTOF were recruited for the final analysis. Within the BMI category, 76 boys and 63 girls were in the normal group, whereas 28 boys and 18 girls were in the excessive adiposity group. Within the FMI category, 77 boys and 60 girls were in the normal group, whereas 27 boys and 21 girls were in the excessive adiposity group. The analysis of the body composition of rTOF subjects showed that there was no statistically significant difference between the subgroups of the two sexes, but both showed a smaller body size than normal Taiwanese children. When comparing the CPF within different BMI and FMI groups, the children in the excessive adiposity group had significantly lower values in metabolic equivalents (MET) at anaerobic threshold, peak MET, and measured peak oxygen consumption (VO2) to predicted peak VO2, regardless of sex. Moreover, boys (60.90%) presented poorer CPF than girls (74.22%, p < 0.001). CONCLUSION In Taiwan, patients with rTOF had poorer CPF than healthy peers. This study found that girls with rTOF had better CPF than boys with rTOF. The effect of gender stereotypes on sports participation and self-efficacy might be one of the contributing factors; however, further investigations are warranted to determine the causal effect.
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Affiliation(s)
- Yung-Liang Chang
- Department of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Tzu-Hsuan Kuan
- Department of General Medicine, E-DA Hospital, Kaohsiung, Taiwan
| | - Chia-Hsin Chen
- Department of Physical Medicine and Rehabilitation, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Ju Tsai
- Institute of Allied Health Sciences, National Cheng Kung University, Tainan City, Taiwan.,Department of Physical Therapy, National Cheng Kung University, Tainan City, Taiwan
| | - Guan-Bo Chen
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Ko-Long Lin
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Physical Medicine and Rehabilitation, Kaohsiung Veteran General Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Sheng-Hui Tuan
- Institute of Allied Health Sciences, National Cheng Kung University, Tainan City, Taiwan.,Department of Rehabilitation Medicine, Cishan Hospital, Ministry of Health and Welfare, Kaohsiung, Taiwan
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22
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The Predicament of Surgical Correction of Tetralogy of Fallot. Pediatr Cardiol 2021; 42:1252-1257. [PMID: 34175987 DOI: 10.1007/s00246-021-02662-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Abstract
Surgery for tetralogy of Fallot has a long history, which may be described as both a success story and a failure story. It is a success story because prognosis without surgery is very poor, but surgery makes it possible for affected babies to reach adulthood and lead productive lives. It is a failure story, however, since we still cannot cure this condition; we can only palliate it as illustrated in the sobering long-term outcome of affected patients. In this review article, we aim to explore the reason for this failure. This may be summed up in terms of the nature of the obstruction to the right ventricular outflow tract, which characterizes this malformation and must be relieved. This obstruction has several possible components, but none may be eliminated without harming the ventricle. There seems to be no 'extra' muscle band in tetralogy of Fallot that may be dispensed with without undermining ventricular function; every muscle band that is there should be there, just like in the normal heart, except that these are thicker than normal and somewhat displaced in tetralogy of Fallot, thus narrowing the right ventricular outflow tract. Consequently, ventricular function deteriorates with every muscle band that is cut, just like in the normal heart. We have to harm the heart in order to repair it. Every repaired Fallot is inevitably a damaged heart. Consequently, repair of this condition cannot be curative at present; it is palliative surgery.
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23
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Abstract
Introduction: Advancements in surgery and management have resulted in a growing population of aging adults with tetralogy of Fallot (TOF). As a result, there has been a parallel growth in late complications associated with the sequelae from the underlying cardiac anomalies as well as the surgical and other interventional treatments.Areas covered: Here, we review challenges related to an aging population of patients with TOF, particularly late complications, and highlight advances in management and key areas for future research. Pulmonary regurgitation, heart failure, arrhythmias, and aortic complications are some of these late complications. There is also a growing incidence of acquired cardiovascular disease, obesity, and diabetes associated with aging. Management of these late complications and acquired comorbidities continues to evolve as research provides insights into long-term outcomes from medical therapies and surgical interventions.Expert opinion: The management of an aging TOF population will continue to transform with advances in imaging technologies to identify subclinical disease and valve replacement technologies that will prevent and mitigate disease progression. In the coming years, we speculate that there will be more data to support the use of novel heart failure therapies in TOF and consensus guidelines on the management of refractory arrhythmias and aortic complications.
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Affiliation(s)
- Jennifer P Woo
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, California, USA
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California, USA
| | - George K Lui
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, California, USA
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Blais S, Marelli A, Vanasse A, Dahdah N, Dancea A, Drolet C, Dallaire F. Comparison of Long-term Outcomes of Valve-Sparing and Transannular Patch Procedures for Correction of Tetralogy of Fallot. JAMA Netw Open 2021; 4:e2118141. [PMID: 34313740 PMCID: PMC8317016 DOI: 10.1001/jamanetworkopen.2021.18141] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE The choice of the right surgical technique for correction of tetralogy of Fallot (TOF) is contentious for patients with a moderate to severe right outflow tract obstruction. The use of a transannular patch (TAP) exposes patients to chronic pulmonary regurgitation, while valve-sparing (VS) procedures may incompletely relieve pulmonary obstruction. OBJECTIVE To compare 30-year outcomes of TOF repair after a VS procedure vs TAP. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study was conducted among all patients with TOF born in the province of Quebec, Canada, from 1980 to 2015 who underwent complete surgical repair. Patients who received a TAP or VS procedure were matched using a propensity score based on preoperative factors in a 1:1 ratio. Data were analyzed from March 2020 through April 2021. EXPOSURES The study groups were individuals who received TAP and those who received VS. The VS group was further stratified by the presence of residual pulmonary stenosis. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality, with 30-year survival evaluated using Cox proportional-hazards models. Secondary outcomes included the cumulative mean number of cardiovascular interventions, pulmonary valve replacements (PVRs), and cardiovascular hospitalizations were evaluated using marginal means/rates regressions. RESULTS Among 683 patients with TOF (401 patients who underwent TAP [58.7%] and 282 patients who underwent a VS procedure [41.3%]), adequate propensity score matching was achieved for 528 patients (264 patients who underwent a VS procedure and 264 patients who underwent TAP). Among this study cohort, 307 individuals (58.1%) were men. The median (interquartile range [IQR]) follow-up was 16.0 (8.1-25.4) years, for a total of 8881 patient-years, including 63 individuals (11.9%) followed up for more than 30 years. Individuals who received a VS procedure had an increased 30-year survival of 99.1% compared with 90.4% for individuals who received TAP (hazard ratio [HR], 0.09 [95% CI, 0.02-0.41]; P = .002). Patients who underwent TAP had an increased 30-year cumulative mean number of cardiovascular interventions compared with patients who underwent a VS procedure without residual pulmonary stenosis (2.0 interventions [95% CI, 1.5-2.7 interventions] vs 0.7 interventions [95% CI, 0.5-1.1 interventions]; mean ratio [MR], 0.36 [95% CI, 0.25-0.50]; P < .001) and patients who underwent a VS procedure with at least moderate residual stenosis (1.3 interventions [95% CI, 0.9-1.9 interventions]; MR, 0.65 [0.45-0.93]; P = .02). Results were similar for PVR, with a 30-year cumulative mean 0.3 PVRs [95% CI, 0.1-0.7 PVRs] for patients who underwent a VS procedure without residual pulmonary stenosis (MR, 0.22 [95% CI, 0.12-0.43]; P < .001) and 0.6 PVRs (95% CI, 0.2-1.5 PVRs) for patients with at least moderate residual stenosis (MR, 0.44 [95% CI, 0.21-0.93]; P = .03), compared with 1.4 PVRs (95% CI, 0.8-2.5 PVRs) for the TAP group. No statistically significant difference was found for cardiovascular hospitalizations. CONCLUSIONS AND RELEVANCE This study found that patients who underwent a VS procedure had increased 30-year survival, fewer cardiovascular reinterventions, and fewer PVRs compared with individuals who underwent TAP, even in the presence of significant residual pulmonary stenosis. These findings suggest that it is beneficial to perform a VS procedure when possible, even in the presence of moderate residual stenosis, compared with the insertion of a TAP.
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Affiliation(s)
- Samuel Blais
- Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Québec, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence, McGill University Health Centre, Montreal, Québec, Canada
| | - Alain Vanasse
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Québec, Canada
| | - Nagib Dahdah
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
| | - Adrian Dancea
- Division of Pediatric Cardiology, McGill University Health Centre, Montreal, Québec, Canada
| | - Christian Drolet
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire de Québec, Québec, Québec, Canada
| | - Frederic Dallaire
- Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Québec, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
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25
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Reply to Abdi et al.-The Big Picture of the Long-term Outcomes of Tetralogy of Fallot. Can J Cardiol 2021; 37:938.e15. [PMID: 33450363 DOI: 10.1016/j.cjca.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 11/22/2022] Open
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Abdi Z, Ahmad M, Manmathan GPR. Is There More to Tetralogy of Fallot Outcomes Than Native Anatomy and Genetic Conditions? Can J Cardiol 2020; 37:938.e13. [PMID: 33373723 DOI: 10.1016/j.cjca.2020.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Zakee Abdi
- Royal Free London NHS Foundation Trust, London, United Kingdom.
| | - Mahmood Ahmad
- Royal Free London NHS Foundation Trust, London, United Kingdom
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27
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Chetan D, Mertens LL. Native Anatomy and Genetic Diagnoses Have a Significant Impact on Long-term Outcomes for Patients With Tetralogy of Fallot. Can J Cardiol 2020; 37:825-826. [PMID: 33309771 DOI: 10.1016/j.cjca.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/04/2020] [Accepted: 12/04/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Devin Chetan
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Luc L Mertens
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
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